Provider Demographics
NPI:1649598749
Name:BOWHALL, KELLIE LYNN (LPN)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:LYNN
Last Name:BOWHALL
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34048 ANTWERP ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:NY
Mailing Address - Zip Code:13673-4106
Mailing Address - Country:US
Mailing Address - Phone:843-704-6110
Mailing Address - Fax:
Practice Address - Street 1:650 STATE ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-2839
Practice Address - Country:US
Practice Address - Phone:315-755-1251
Practice Address - Fax:315-291-6601
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-13
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC55304164W00000X
NY277760164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse